New Member Application

Clinical Membership in the Guild is open to professionals engaged in the conduct of psychotherapy on Bainbridge Island. Members who join after January 15, 2007 must be licensed mental health professionals in the State of Washington who have earned a minimum of a Master’s degree in one of the established mental health disciplines from an accredited college, university, or professional training program (including, but not limited to psychiatry, clinical or counseling psychology, clinical social work, marriage and family therapy, and mental health counseling). The fee for clinical membership is $75.00. For payment options please see our Membership page.

 

Application for clinical membership:

* Indicates a required field.

First Name*
Middle/Init
Last Name*
Primary Address*
City/State/Zip*
Second Address
City/State/Zip
Primary Phone (for publication)*
Secondary Phone (for publication)

Email*

Website URL

Credentials* Check as many as apply

Practice Name

Description of Your Practice*

Notify me of routine Guild business via*

Issues and Concerns*
If a specialty of yours is not listed, we recommend that you mention the specialty area in the “description of your practice” above.

Treatment Modalities* Check as many as apply

Special Treatment Populations* Check as many as apply

AdolescentsAdultsChildrenCouplesFamiliesGay and LesbianGeriatricsTransgender
Additional Services

Community WorkshopsGroup TherapyProfessional SupervisionProfessional Training

Description of Additional Services

Insurance Payments*

Not applicable, there is no fee for service provided.Private pay only, no insurance accepted.Private pay, limited insurance provider.Will provide receipt to submit for out-of-network reimbursement.Sliding scale or reduced fee possible.Preferred provider for many insurances.

Insurance Providers

AetnaAlliantAnthemAPSBridgespan HealthCignaCrime VictimsDSHS/Medical CouponsFirst ChoiceGreatWest Health CareHelplineKaiser PermanenteKaiser Permanente PPOL&ILifewise PremeraMagellan Health ServicesMedicaidMedicareMHNMolinaPremeraRegenceRegence FEPRetail ClerksTriCare / TriWestUnited BehavioralUnited HealthcareValue OptionsVirginia MasonWA Basic Health PlanZenith Administrators

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